Nursing SBAR Note Template and Examples

The SBAR method plays a key role in improving communication in healthcare settings by:

• Ensuring patient safety: With clear and concise communication, SBAR helps prevent errors that can occur from missing or unclear information, ultimately enhancing patient safety.
• Improving healthcare outcomes: SBAR ensures that all relevant details are communicated effectively, allowing healthcare providers to make more informed and timely decisions about patient care.
• Preventing miscommunication: By structuring conversations in a predictable format, SBAR reduces the chances of key information being overlooked or misinterpreted, which can often lead to dangerous medical errors.

Here are some tips to help you fill out SBAR notes effectively, ensuring that your communication is both accurate and efficient.

• Be concise and to the point: Focus on the most critical information. Avoid unnecessary details that may detract from the urgency or clarity of the message.
• Ensure all relevant information is included: Summarize only pertinent details of the patient’s history, vital signs, or recent events that have influenced the current situation.
• Organize your thoughts before starting: Prior to filling out the SBAR template, mentally organize the information you want to present.
• Stay objective in your assessment: Base your clinical assessment on observable facts and medical evidence rather than personal opinions.
• Be clear in recommendations: When making recommendations, provide specific actions that need to be taken to ensure that the receiver knows exactly what steps to follow next.
• Review before submission: Double-check your notes to ensure accuracy, completeness, and that no key details have been missed.

Using SBAR templates provides numerous advantages in clinical communication, ensuring that critical information is conveyed clearly and effectively between healthcare professionals. Here are some advantages of using SBAR templates:

• Consistency: SBAR templates provide a standardized way to communicate patient information, reducing variations in how data is shared between healthcare providers. This helps ensure that all critical details are conveyed in the same structured format.
• Clarity: Using a template ensures that information is presented in an organized, easy-to-understand manner, which helps avoid misunderstandings, especially in fast-paced clinical environments.
• Time-saving: SBAR templates allow healthcare professionals to quickly document and relay essential patient information without having to start from scratch every time, helping to speed up communication during critical situations.

How TextExpander Can Help

TextExpander streamlines the use of SBAR templates by allowing healthcare professionals to access pre-built templates quickly, improving the speed and consistency of their communication.

• Quick Access: TextExpander provides immediate access to pre-created SBAR templates, allowing healthcare professionals to insert structured information into their notes or reports with just a few keystrokes.
• Customization: The snippets can be tailored to specific patient needs, helping to maintain flexibility while ensuring the SBAR format is followed.
• Efficiency: By reducing the time spent manually typing out information, TextExpander streamlines documentation and communication, freeing up time for patient care.

Here’s a basic SBAR template for healthcare use:

SBAR Examples

Example 1: Chest Pain in Emergency Room

Situation: This is Nurse Jane from the emergency department. I am calling about Mr. John Smith, a 55-year-old male, who presented with acute chest pain that started an hour ago.

Background: Mr. Smith has a history of hypertension and hyperlipidemia. He reports the chest pain as a pressure-like sensation, radiating to his left arm. He denies nausea or shortness of breath. His vitals: BP 150/95, HR 110, RR 18, O2 saturation 95% on room air. ECG shows ST depressions in the anterior leads.

Assessment: I believe the patient is experiencing an acute coronary syndrome. His pain has not been resolved with nitroglycerin, and his ECG findings are concerning.

Recommendation: I recommend that you come evaluate Mr. Smith immediately. I also suggest initiating aspirin therapy and preparing for potential transfer to the cardiac unit for further management.

Example 2: Mental Health Crisis in a Psychiatric Unit

Situation: This is Dr. Lee, a psychiatrist in the inpatient psychiatric unit. I am calling about Mary Thompson, a 32-year-old female, admitted with severe depression and suicidal ideation.

Background: Mary has a history of bipolar disorder and multiple hospitalizations for depression. She was admitted two days ago and has been on sertraline 100mg daily. She is now refusing medication, becoming increasingly agitated, and expressing thoughts of self-harm.

Assessment: Mary’s agitation has escalated, and she is verbally threatening staff. Despite attempts at de-escalation, her condition is worsening. There is concern that she may become physically aggressive.

Recommendation: I recommend urgent psychiatric evaluation and a possible adjustment to her medication regimen. We may need to consider sedation or transferring her to a higher level of care for safety.

Example 3: Post-Operative Patient (with Fever)

Situation: This is Nurse Mike from the surgical ward. I am calling about Mr. David Wilson, a 45-year-old male, post-op day 2 following an appendectomy.

Background: Mr. Wilson has a history of diabetes. His surgery was uncomplicated. He was afebrile until this morning when his temperature spiked to 38.5°C. His wound site is red and tender with some purulent drainage. Current vitals: BP 130/80, HR 105, RR 22, temp 38.5°C.

Assessment: I suspect Mr. Wilson may have developed a post-op wound infection. His diabetes may be complicating the healing process.

Recommendation: I recommend starting broad-spectrum antibiotics and obtaining a wound culture. Would you like to order additional tests or imaging?